Provider Demographics
NPI:1235736778
Name:FREE, BETHANY ANNA (FNP- BC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANNA
Last Name:FREE
Suffix:
Gender:F
Credentials:FNP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 NEW WINE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-2511
Mailing Address - Country:US
Mailing Address - Phone:662-567-2865
Mailing Address - Fax:
Practice Address - Street 1:1002 E MADISON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2428
Practice Address - Country:US
Practice Address - Phone:662-567-2865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty